993
Total cases
45%
Preventable or possibly preventable
53%
With coroner recommendations
29%
Escalation failure identified
Specialty tagging, error classification, and clinical flags are AI-generated and may contain inaccuracies. Always refer to the original finding.
74y · Male·Pulmonary thromboembolism due to right deep vein thrombosis
Richard Holden, aged 74, presented to his GP Dr C. multiple times in August 2020 with progressive shortness of breath and wheeziness. Dr C. diagnosed and treated asthma despite worsening symptoms and failure to respond t…
62y · Male·multi-organ failure on a background of aortic regurgitation and ischaemic heart …
A 62-year-old man with aortic regurgitation and coronary artery disease died from multi-organ failure after emergency cardiothoracic surgery. His elective surgery was cancelled twice (14 and 22 Aug 2023) due to prioritiz…
37y · Female·morbid obesity with dilated cardiomyopathy and obstructive sleep apnoea
Ms UT, a 37-year-old woman with treatment-resistant schizophrenia, died of morbid obesity with dilated cardiomyopathy and obstructive sleep apnoea. She was prescribed clozapine, an effective but potentially cardiotoxic a…
88y · Female·Cardiac failure secondary to pacemaker failure and pacemaker battery exhaustion
This case involves an 88-year-old woman with a pacemaker who became lost to follow-up after her last clinic visit in May 2019, when no follow-up appointment was arranged. Without systematic tracking between the specialis…
14y · Female·unascertained natural causes – possibly encephalitis leading to seizure or sudde…
SMS, a 14-year-old previously healthy girl, collapsed unexpectedly at home on 10 October 2021 and was found unresponsive and not breathing. Immediate resuscitation was commenced by family members and emergency services, …
72y · Male·Complications of suspected upper gastrointestinal tract haemorrhage, hospital ac…
A 72-year-old man with metastatic squamous cell lung cancer and multiple serious comorbidities was admitted to Ballarat Hospital in July 2024 with lethargy, fatigue, and rapid atrial fibrillation. Due to medication chart…